Occupational therapy practice guidelines for cancer rehabilitation with adults.

2017·0.12 MB·English

by  National Guideline Clearinghouse (NGC)

General
Guideline Title
Occupational therapy practice guidelines for cancer rehabilitation with adults.
Bibliographic Source(s)
Braveman B, Hunter EG. Occupational therapy practice guidelines for cancer rehabilitation with adults.
Bethesda (MD): American Occupational Therapy Association, Inc. (AOTA); 2017. 67 p. [283 references]
Guideline Status
This is the current release of the guideline.
This guideline meets NGC's 2013 (revised) inclusion criteria.
NEATS Assessment
National Guideline Clearinghouse (NGC) has assessed this guideline's adherence to standards of
trustworthiness, derived from the Institute of Medicine's report Clinical Practice Guidelines We Can Trust.
= Poor = Fair = Good = Very Good = Excellent
Assessment Standard of Trustworthiness
Disclosure of Guideline Funding Source
YES
Disclosure and Management of Financial Conflict of Interests
Guideline Development Group Composition

UNKNOWN Multidisciplinary Group
YES Methodologist Involvement
Patient and Public Perspectives
Use of a Systematic Review of Evidence

Search Strategy
Study Selection
Synthesis of Evidence
Evidence Foundations for and Rating Strength of

Recommendations
Grading the Quality or Strength of Evidence
Benefits and Harms of Recommendations
Evidence Summary Supporting Recommendations
Rating the Strength of Recommendations
Specific and Unambiguous Articulation of Recommendations
External Review
Updating
Recommendations
Major Recommendations
Note from the National Guideline Clearinghouse: In addition to the evidence-based recommendations
below, the guideline includes extensive information on the evaluation process and intervention strategies
for adults with cancer.
Definitions for the strength of recommendations (A–D, I) and levels of evidence (I–V) are provided at the
end of the "Major Recommendations" field.
Recommendations for Occupational Therapy Interventions for Adults with Cancer
Interventions in Multidisciplinary Rehabilitation
Multidisciplinary rehabilitation programs are beneficial to improve function and participation
regardless of stage of cancer or age of the cancer survivor (A)
Multidisciplinary rehabilitation programs are beneficial pre- and posttreatment (B)
Multimodal interventions, including aquatic therapy and other exercise, are beneficial for breast
cancer survivors (B)
Cognitive-behavioral therapy programs improve quality of life (QOL) and attention abilities (B)
Rehabilitation in advanced, progressive, recurrent cancer improves QOL and is cost effective (B)
Rehabilitation with outcome focused on single domain is more effective than rehabilitation with
multiple domains (C)
Rehabilitation that consists of telephone-delivered, problem-solving skills provided to rural breast
cancer patients undergoing chemotherapy improves function and QOL (C)
Interventions That Address Symptom Management
Physical activity and exercise to reduce cancer-related fatigue and improve QOL results in no adverse
effects such as increased fatigue or falls (A)
Problem-solving, energy conservation, and education to reduce breathlessness (A)
Sleep behavior modification, education, and problem solving for pain management (B)
Cognitive–behavioral therapy for cancer-related fatigue (B)
Interventions That Address Psychosocial Needs
Cognitive–behavioral and educational intervention to reduce anxiety and reduce depression in the
short term (3 months) (A)
Mindfulness therapy to reduce symptoms of anxiety and depression (A)
Short-term life review to improve spiritual well-being for those with terminal cancer (B)
Group stress management to improve psychosocial adjustment in breast cancer survivors (B)
Problem-solving therapy by phone to improve QOL and reduce stress for women with breast cancer
(B)
Cognitive–behavioral therapy to improve QOL and decrease limitations from symptoms during
chemotherapy and during advanced-stage cancer (B)
Structured multidisciplinary QOL and self-management interventions to improve QOL for older
survivors (B)
Expressive writing activities to improve QOL for early-stage breast cancer survivors (B)
Interventions That Address Physical Activity
Physical activity to improve QOL; reduce cancer-related fatigue; and increase muscle tone, strength,
and lung capacity (A)
Physical activity is safe and feasible for the majority of cancers, stages of cancer, and ages of
survivors and provides physiological and psychological benefits (A)
Physical activity to improve health-related quality of life (HRQOL) (B)
Physical activity to improve sleep quality during cancer treatment (B)
Physical activity to increase sexual activity (B)
Counseling added to physical activity to maintain participation in exercise (B)
Combining diet and exercise to reduce functional decline (B)
Interventions That Address Lymphedema Management
Compression bandages worn daily to maintain volume control (A)
Compression bandages combined with therapy that includes skin care, range of motion (ROM), and
strengthening to maintain volume control (A)
Exercise to increase ROM, QOL, and weight loss does not exacerbate lymphedema (A)
Low-frequency, low-intensity electrotherapy to reduce feelings of pain, heaviness, and tightness
when treating lymphedema (B)
Low-frequency, low-intensity electrotherapy to reduce lymphedema volume (C)
Aqua lymphatic therapy to reduce lymphedema volume (C)
Manual lymph drainage and self-management alone to reduce lymphedema volume (C)
Interventions That Address Complementary Health Approaches and Integrative Health (CHAIH)
Mindfulness-based interventions to improve QOL and reduce anxiety, depression, and stress (B)
Yoga to improve QOL and well-being and reduce stress and the use of sleep medication (B)
Qigong to improve QOL, mood, and immune responses and to reduce fatigue and inflammation (B)
Dance/movement therapies to improve QOL for women with breast cancer (C)
Dance/movement therapies to improve physical health in women with breast cancer (I)
Interventions That Use Physical Agent Modalities (PAMs)
Neuromuscular electrical stimulation (NMES) combined with traditional swallowing training to reduce
dysphagia following treatment for head and neck cancer (A)
Low-frequency, low-intensity electrotherapy to reduce feelings of pain, heaviness, and tightness
when treating lymphedema of the upper extremity (B)
Low-frequency, low-intensity electrotherapy to reduce lymphedema volume (C)
Transcutaneous electrical nerve stimulation (TENS) for cancer-related pain (C)
Interventions That Address Sexuality
Physical training (strength, interval, and home-based activities) to improve interest in sex and
sexual activity among male prostate cancer survivors (A)
Couples-based psychosocial interventions to reduce sexual problems after cancer diagnosis and
treatment (C)
Interventions That Address Return to Work
Multidisciplinary interventions (physical, psychological, and vocational) to improve return to work (B)
Rehabilitation using high-intensity physical training (strength, interval, and home-based activity) to
limit reduction in ability to work (B)
Occupational therapy focusing on vocational and social rehabilitation to improve QOL and return to
work for breast cancer survivors (C)
Definitions
Strength of Recommendations
A–There is strong evidence that occupational therapy practitioners should routinely provide the
intervention to eligible clients. Good evidence was found that the intervention improves important
outcomes and concludes that benefits substantially outweigh harm.
B–There is moderate evidence that occupational therapy practitioners should routinely provide the
intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is
moderate certainty that the net benefit is moderate to substantial.
C–There is weak evidence that the intervention can improve outcomes. It is recommended that the
intervention be provided selectively on the basis of professional judgment and patient preferences. There
is at least moderate certainty that the net benefit is small.
I–There is insufficient evidence to determine whether or not occupational therapy practitioners should be
routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality,
or conflicting and the balance of benefits and harm cannot be determined.
D–It is recommended that occupational therapy practitioners do not provide the intervention to eligible
clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs
benefits.
Note: Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language from the U.S. Preventive Services
Task Force (2016). Suggested recommendations are based on the available evidence and content experts' clinical expertise regarding the
value of using such evidence.
Levels of Evidence for Occupational Therapy Outcomes Research
Levels of Definition
Evidence
Level I Systematic reviews, meta-analyses, and randomized, controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case control)
Level III One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design,
case series)
Level V Case reports and expert opinions, which include narrative literature reviews and
consensus statements
Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, &
W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72.
Clinical Algorithm(s)
None provided
Scope
Disease/Condition(s)
Cancer and secondary conditions related to cancer and its treatment including:
Cancer-related fatigue
Deconditioning
Cancer-related cognitive dysfunction
Cancer-induced neuropathy
Cancer-related pain
Cardiovascular and pulmonary considerations
Graft versus host disease
Lymphedema
Postsurgical complications
Psychosocial issues: body image, depression, and anxiety
Guideline Category
Counseling
Management
Rehabilitation
Treatment
Clinical Specialty
Nursing
Oncology
Physical Medicine and Rehabilitation
Psychiatry
Psychology
Radiation Oncology
Speech-Language Pathology
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Hospitals
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Speech-Language Pathologists
Guideline Objective(s)
To provide an overview, on the basis of existing evidence of the effects of various interventions, of
occupational therapy interventions for individuals with cancer who are undergoing rehabilitation
To help guide future decisions on areas for research by highlighting areas in which promising
interventions may lack enough evidence of a clear benefit or in which available interventions fail to
meet specific needs of clients with cancer
To be useful to many entities involved in providing occupational therapy services to individuals with
cancer, such as occupational therapy practitioners, team members, educators, clients, families,
caregivers, third-party payers, and policymakers
Target Population
Adults with cancer
Interventions and Practices Considered
1. Interventions in multidisciplinary rehabilitation
2. Interventions that address symptom management
3. Interventions that address psychosocial needs
4. Interventions that address physical activity
5. Interventions that address lymphedema management
6. Interventions that address complementary health approaches and integrative health
7. Interventions that use physical agent modalities
8. Interventions that address sexuality
9. Interventions that address return to work
Major Outcomes Considered
Effectiveness of interventions as determined by:
Performance of activities of daily living and instrumental activities of daily living
Return to work
Participation in leisure and social activities
Symptom and complications management
Quality of life
Methodology
Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
The systematic review sought to answer the following question: What is the effectiveness of cancer
rehabilitation interventions within the scope of occupational therapy practice to address the activity and
participation needs of adult cancer survivors in activities of daily living, instrumental activities of daily
living, work, leisure, social participation, and rest and sleep?
Method
Search terms for the review were developed by the methodology consultant to the American Occupational
Therapy Association (AOTA) Evidence-based Practice (EBP) Project and AOTA staff, in consultation with
the review authors of the question and the advisory group. The search terms were developed not only to
capture pertinent articles but also to make sure that the terms relevant to the specific thesaurus of each
database were included. Table D.1 in the original guideline document lists the search terms related to
population (adults with cancer), types of intervention, outcomes, sequelae, and types of study design
included in the systematic review. A medical research librarian with experience in completing systematic
review searches conducted all searches and confirmed and improved the search strategies.
Databases and sites searched included MEDLINE, PsycINFO, CINAHL, and OTseeker. In addition,
consolidated information sources, such as the Cochrane Database of Systematic Reviews, were included
in the search. These databases are peer-reviewed summaries of journal articles and provide a system for
clinicians and scientists to conduct systematic reviews of selected clinical questions and topics. Reference
lists from articles included in the systematic reviews were examined for potential articles, and selected
journals were hand searched to ensure that all appropriate articles were included.
Inclusion and exclusion criteria are critical to the systematic review process because they provide the
structure for the quality, type, and years of publication of the literature that is incorporated into a review.
Included articles were peer-reviewed scientific literature on participants with cancer published in English
between 1995 and 2014 and within the scope of practice of occupational therapy. The review excluded
data from presentations, conference proceedings, non–peer-reviewed research literature, dissertations,
and theses. The review also excluded studies focusing on caregivers, family members, and friends, rather
than on cancer survivors, and studies of childhood cancer. Studies included in the review provide Level I,
II, and III evidence. Level IV evidence was included only when higher level evidence on a given topic was
not found; no Level V studies were included.
Selection of Articles
A total of 8,436 citations and abstracts were identified through searches of databases and reference lists
of articles included in the review. Removal of duplicates left 6,717 citations and abstracts. The three-
person review team completed the step of eliminating references on the basis of citations and abstracts.
A total of 945 full-text articles remained and were retrieved. After the initial full-text review, the articles
were reduced to 437, which received an in-depth full review.
Number of Source Documents
The 138 articles included in the final review included 129 Level I, 4 Level II, 4 Level III, and 1 Level IV
studies.
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence for Occupational Therapy Outcomes Research
Levels of Definition
Evidence
Level I Systematic reviews, meta-analyses, and randomized, controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case control)
Level III One group, nonrandomized (e.g., before-after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design,
case series)
Level V Case reports and expert opinions, which include narrative literature reviews and
consensus statements
Note: Adapted from "Evidence-based medicine: What it is and what it isn't." D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, &
W. S. Richardson, 1996, British Medical Journal, 312, pp. 71-72.
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
The team working on the focused question reviewed the articles according to their quality (scientific rigor
and lack of bias) and levels of evidence. Each article included in the review was abstracted using an
evidence table that provides a summary of the methods and findings of the article. The American
Occupational Therapy Association (AOTA) staff and the Evidence-Based Practice (EBP) Project consultant
reviewed the evidence tables to ensure quality control. All studies are summarized in full in the evidence
tables in Appendix E in the original guideline document.
The risk of bias of individual studies was assessed using the methods described by Higgins, Altman, and
Sterne (2011). The method for assessing the risk of bias of systematic reviews was based on the
measurement tool developed by Shea et al. (2007). An analysis of the articles included in the systematic
review that served as the basis of this practice guideline was completed using risk-of-bias tables (see
Appendix E in the original guideline document).
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
A major focus of the American Occupational Therapy Association's (AOTA's) Evidence-Based Practice (EBP)
projects is an ongoing program of systematic review of multidisciplinary scientific literature, using focused
questions and standardized procedures to identify practice-relevant evidence and discuss its implications
for practice, education, and research. An evidence-based perspective is founded on the assumption that
scientific evidence of the effectiveness of occupational therapy intervention can be judged to be more or
less strong and valid according to a hierarchy of research designs, an assessment of the quality of the
research, or both.
AOTA uses standards of evidence modeled on those developed in evidence-based medicine. This model
standardizes and ranks the value of scientific evidence for biomedical practice using a grading system. In
this system, the highest level of evidence, Level I, includes systematic reviews of the literature, meta-
analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either
an intervention or a control group, and the outcomes of both groups are compared. Other levels of
evidence include Level II studies, in which assignment to a treatment or a control group is not
randomized (cohort study); Level III studies, which do not have a control group; Level IV studies, which
use a single-case experimental design, sometimes reported over several participants; and Level V
studies, which are case reports and expert opinion that include narrative literature reviews and consensus
statements.
The systematic review on adults with cancer was supported by AOTA as part of the EBP Project. AOTA is
committed to supporting the role of occupational therapy in this important area of practice.
The systematic review covered the period from 1995 to 2014 because occupational therapy practitioners
need access to the results of the latest and best available literature to support intervention within the
scope of occupational therapy practice. The question that was the basis for the review was developed by
the review authors and reviewed by an advisory group of content experts in the field (occupational
therapists and physician oncologists), AOTA staff, and the methodology consultant to the AOTA EBP
Project.
Rating Scheme for the Strength of the Recommendations
Strength of Recommendations
A–There is strong evidence that occupational therapy practitioners should routinely provide the
intervention to eligible clients. Good evidence was found that the intervention improves important
outcomes and concludes that benefits substantially outweigh harm.
B–There is moderate evidence that occupational therapy practitioners should routinely provide the
intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is
moderate certainty that the net benefit is moderate to substantial.
C–There is weak evidence that the intervention can improve outcomes. It is recommended that the
intervention be provided selectively on the basis of professional judgment and patient preferences. There
is at least moderate certainty that the net benefit is small.
I–There is insufficient evidence to determine whether or not occupational therapy practitioners should be
routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality,
or conflicting and the balance of benefits and harm cannot be determined.
D–It is recommended that occupational therapy practitioners do not provide the intervention to eligible
clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs
benefits.
Note: Criteria for level of evidence and recommendations (A, B, C, I, D) are based on standard language from the U.S. Preventive Services
Task Force (2016). Suggested recommendations are based on the available evidence and content experts' clinical expertise regarding the
value of using such evidence.
Cost Analysis
Moderate evidence indicates that rehabilitation for advanced, progressive, recurrent cancer is cost-
effective and increases quality of life.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
This Practice Guideline was reviewed by a group of content experts on cancer that included a consumer
representative and policy experts.
Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see the "Major
Recommendations" field).
After the review process, 138 articles were included in the final review (129 Level I, 4 Level II, 4 Level
III, 1 Level IV). The articles were grouped into nine broad categories related to interventions that
address:
Multidisciplinary rehabilitation programs
Symptom management
Psychosocial interventions
Physical activity
Lymphedema management
Complementary health approaches and integrative health (CHAIH)
Physical agent modalities
Sexuality
Return to work
Benefits/Harms of Implementing the Guideline
Recommendations
Potential Benefits
This guideline may be used to assist:
Occupational therapists and occupational therapy assistants in providing evidence-based
interventions to adults with cancer
Occupational therapists and occupational therapy assistants in communicating about their services
to external audiences
Other health care practitioners, case managers, clients, families and caregivers, and health care
facility managers in determining whether referral for occupational therapy services is appropriate
Third-party payers in determining the medical necessity for occupational therapy
Legislators; third-party payers; federal, state, and local agencies; and administrators in